Florida sleeve is a safe and effective technique for valve salvage in acute stanford type A aortic dissection

Malposition of an Internal Aortic Annuloplasty Ring After Acute Type A Aortic Dissection Repair

Poor tissue quality of adventitia and intima makes aortic root repair complex in patients with acute type A aortic dissection. The management of aortic root repair remains controversial. Internal aortic annuloplasty devices provide a standardized aortic valve repair technique to reduce and prevent annular dilation, while the modified Florida sleeve (mFS) procedure is an aortic root remodeling technique that does not require coronary artery reimplantation. However, little is known about the long-term durability of internal aortic annuloplasty with the hemispheric aortic annuloplasty remodeling ring (HARRT) combined with a mFS procedure in acute type A aortic dissection repair. A 52-year-old man had initial type A aortic dissection repair with an internal aortic annuloplasty ring and a mFS technique. He presented with dyspnea on exertion and intermittent chest pain one year later. Transesophageal echocardiogram revealed malposition of aortic annuloplasty ring and severe aortic insufficiency. He underwent a redo sternotomy with aortic valve replacement. Intraoperative findings demonstrated the aortic annuloplasty ring had dislodged from under the left and right coronary annulus and was adherent to the base of the noncoronary leaflet. The annuloplasty ring and aortic valve leaflets were excised and replaced with a mechanical aortic valve.

Treatment options for isolated aortic valve insufficiency: a review

Aortic insufficiency (AI) is a valvular disease with increasing prevalence in older patients. The modern era provides numerous options for the management of AI which is explored here. Traditional interventions included aortic valve replacement with either mechanical or bioprosthetic aortic valves. While the former is known for its durability, it has grown out of favor due to the potential complications of anticoagulation. The preference for bioprosthetic valves is thus on the rise, especially with the advancements of transcatheter technology and the use of valve-in-valve therapy. Surgical options are also no longer limited to replacement but include complex techniques such as those required for aortic valve repair, Ozaki neocuspidization, Ross procedure and valve-sparring aortic root repair. Transcatheter options for the management of AI are not commercially available currently; however, preliminary data from ad-hoc trials, showed promising results and potential use of transcatheter technology in a variety of patients with pure AI.

Current controversies in aortic valve-preserving surgery

The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.